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HomeMy WebLinkAbout1315A (7) • WORKERS'COMPENSATION DECLARATION APPLIC�ATION FOR PLUsM�B� G PERM� ��/� .I hereby,offirm �hot I have a tertifica�e of cnnsent to self 78AB87A � vi j insure,or a cenifico}e of Workers'Compensalion Insvranca, CE B77(REV.8/8B) � , or a cert�Red copy rheare� (�qa 3 lcb.C.) . . � � LI pOolicyNon.�„j� ompany � ' .COUNTY OF LOS ANGELES - DEPT., ''PUCBLIC�WORKS . Canified copy is hereby furnished. � � � �� �J . y� FOR AVMIGNT TO flll W(NtINT OR TVPEJ BURDING � �j Ceriified topy is filed with the county building Inspec- /�� � ' t i o n d e p o r t m e n l. NUMBER FIXTURE OR ITEM � F E E ��`m � - l �O Do�e�^��AppliGanl ��C� WATERCLOSFf � NEAREST - .. . CERTIFICATE OF El(FMVTION FROM WORKERS' BATH TU6 - . . �ROSS ST. �F�W\'D � COM�ENSATION INSURANCE SN�R OWNER . . . (Thls s�cNon nNd eof b�complN�d II fh�werk Inrelwd by � ��� fh�p�rmk It for on�hundnd dallen(SI00�or buJ InVATORr qpp�� . . . - . I tenify Ihot in the performanca of Ihe work fOr which Ihis ._ perm�t is issued,I sholl not amploy ony parson in ony monner ( SINK ��TY C o�.,;n � � ��.�.9 6 - s � � so as to become iubjacl�o�he Wukers'Compenwtion Laws. DiSt�WASHER - - o�coH,r�ncroR �-S Ch P bate ' dppliConf - � QOTNES WASHER ADDRESS 'O� � S��•�l, � �ICE TO APPLICANT: If, af�er making Ihis Gertificota of SWIMMING POOt RKEPTOR mD��on, you shovld become subject��o �he Workers' ` ��Compenso�ion prov�srons of the tabor Cade,you musr forth• ��� ��O.QY� Cp ����ba�-ao wiih tomply with suth provisions or this permit sholl be LAWN SPRINKtER SYSTEM STAIE ^� �IC, desmed revoked. � � WATER HEATER Q� ����� U �b CIASS C LI�ENSED CONTRACTORS OKLARATION DISTRICT Np. BY �I haeb oRirm Ihof 1 om licensed ondar G.45 Srsiena OUiiEiS � y pfOViSIOM O{C�tOpIN 9 � j Q a�o t� e (commencing wiM SecNon 700p)of Division 3 of fM 8usineu OUTlET50vER � and Vrofeuions Code,and my Ikente is in full force and eifeU. 5 PER SvStEM 3��0�� C,3 oA�� //,?4��5' VALIDATION � Litense Number Lit.Clau� � ( FINAL / O Controctor ��n'� �e� BY �y V pW I om eYampt unde�$ee. a fd B.BP.C.for this reason Z Plan check fee . . . . . ��e� . %.UMBING PERMIT ISSUING FEE§ 'D D ► Sgnarure '1 3 1.5 A ' TOTAL FEE 5 � ae . . . .5 Pion[hetk oppliconf � . SINGIE FAMiLY . I � �S 4 J�O 1 HOME OWNER-BUlLDER�ECUIRATION - Name ^�_U.r . ,Feby affirm Ihat I am exempt from�he CoMracbr'a litenae Address � � - p ' '��" , tow for the following rea�on(Section 70.31.5,Buaioeu ond P+ofessions Code): Ciy � Tel.No. 0�.�2�8 7 ❑ �,os owner of the propr�y,.will do the work ond fhe svucbre is not intended or offered for wle�SMion . . . . . .. . _ . . - 704r,Business and Vrofensions Code). � CONSTRUCTION LENDMG AGENCY � � � � � - -� I here6y offirm ihut there b a tonstroction le�ding agency for the performonce of the work for which this permit is issoed � - � �� — � � � - , (Sec.3097,Civ.C.). ' Lender's Name � � lender's Addrets � � I certify that 1 have read this opplication ond slale thot Ihe .. . . . �-► . � above informolion is corroct.I agree fo mmply with oll Couny � � ordinonces and$tale lows regulating Plum6ing,ond hereby au�hwize represen�otives of�his Couny ro eMer upon Ihe �� - � � - � � obo�e-mentio�ed propeny fo.inapection purposes. 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